There is great fear in the disability community today about the slow and inevitable transition from Medicaid fee-for-service to Medicaid managed care, and for good reason. For most, managed care conjures up pictures of bureaucracy and rationing, the erosion of choice in favor of the almighty dollar. The rise of the HMO was a horror story in the private sector that many of our most in need are just waiting to see replayed. Why then are people virtually beating down the doors to join the One Care Program, a managed care program at Commonwealth Care Alliance (CCA)? Why do I hear, and share, the lament that CCA's services are currently only available to those dually eligible for Medicare and Medicaid, because the capitated payment system on which they function is only available as part of a demonstration project for dually eligible beneficiaries. Why do I hear clamoring for a capitated option for Medicaid only beneficiaries?
The answer can be found in one phrase. “Managed care, not managed cost.” I first heard these words out of the mouth of Dr. Robert Master in the summer of 2003, when I sat with him as he pitched the idea of CCA to potential funders. His decades of demonstration work at what was then the Boston Community Medical Group had proven beyond a shadow of a doubt that caring for the whole person improves health and minimizes cost. Why is this?
Crisis control, hospital admission, emergency medicine, and end of life care make up the most expensive parts of any health care system. A nickel prevention here is worth many dollars of cure. Dr. Master and his team learned that if you get to know an individual, learn their needs, their wants, and how their individual bodies work, and if you choose to meet those needs, without regard to a prearranged menu of services, then health care works better and costs less. Routine maintenance, often nickel and dimed by private insurance or fee-for-service Medicare and Medicaid, can prevent crises and hospitalizations. Creative care strategies tailored to the patient can do even more. When the only barrier to paying for medical care is that the doctor and the patient agree on its necessity, amazing things happen. Then there is end of life.
Most of us in the private insurance world build strong relationships with our doctors as we age. Under their thoughtful care, we craft living wills and other end of life plans, we discuss our needs and designate loved ones with powers of attorney. We give careful thought to the balance between the natural extension of our lives and the needless prolonging of our suffering. Traditional government programs, with their impersonal bureaucracies and overtaxed professionals, often fail to participate in, let alone prompt, these discussions. Further, many with disabilities have not been exposed to the cultural norms that Ithose of us who are the educated children of educated professionals did. They have never drafted these plans, and, once a final illness takes the ability to speak for themselves, their doctor has no choice but to fight for the last agonizing breath, often taken long after conscious life has departed. The final service of truly caring managed care is to work with patients to discuss these important questions long before treatment decisions must be made. End of life becomes orderly, often much more pleasant, and, though we hate to admit it, much cheaper. This allows limited dollars to go for quality of life for the living.
In short, when care is truly managed, outcomes are better and cost is less. And you need not take the word of a health plan. Rather just ask the many Massachusetts Medicaid beneficiaries clamoring for CCA. This is a model that should be studied and replicated, a medical practice that is truly first and foremost about care.